Follow up study of angina in patients aged 30 to 59 in general practice.

In 1979, 51 general practitioners in the Northern region identified 336 patients aged 30 to 59 who had angina pectoris. Information was obtained on their treatment and how angina affected their daily lives. This study reviews the same patients after an interval of four years. Of the 307 who were not lost to follow up, 38 (12%) had died and 44 (14%) were free from angina in the last year. Drugs seemed to be used to their best advantage, with a fourfold increase in the use of the newer calcium antagonists and long acting trinitrate preparations. Many patients still suffered from angina, which was severely affecting their daily lives, but only 41 patients had had exercise electrocardiograms recorded or more detailed investigations; this includes 16 (6%) patients who had had coronary artery bypass surgery.     

Long term effect on mortality of stopping smoking after unstable angina and myocardial infarction.

Subjects who stop smoking cigarettes after myocardial infarction have an improved rate of survival compared with those who continue, but to date it was not known whether the benefit persisted for more than six years. A total of 498 men aged under 60 years who had survived a first episode of unstable angina or myocardial infarction by two years were followed up by life table methods for a further 13 years. Mortality in those who continued to smoke was significantly higher (82.1%) than in those who stopped smoking (36.9%). These differences increased with time. Mortality in those who were non-smokers initially and who continued not to smoke was intermediate (62.1%). The adverse effect of continued smoking was most pronounced in those with unstable angina. Continuing to smoke increased the rate of sudden death to a greater degree in those with less severe initial attacks, while the effect of smoking on fatal reinfarctions was most apparent in those with a more complicated presentation. These findings suggest that stopping cigarette smoking is the most effective single action in the management of patients with coronary heart disease.     

Course of angina pectoris after an acute coronary event.

The course of postcoronary angina pectoris was examined in 555 men who had survived a first attack of myocardial infarction or unstable angina. Patients were aged less than 60 and were followed up yearly for up to 17 years. Only 25 (4.5%) had coronary artery bypass surgery. Most patients with angina were treated by nitrates alone. One year after infarction 24.1% of survivors (124/515) reported the presence of angina pectoris, and the proportions at five, 10, and 15 years were 29.9%, 30.4%, and 43.5% respectively. Seventeen years after the initial event 35.3% of the survivors had never reported postcoronary anginal symptoms. The patients who experienced anginal symptoms in the year after their coronary attack had a poorer long term survival than the group who were symptom free over the first year. These patients also had longer subsequent periods with angina, though in 41.7% angina resolved before death after a median of 2.9 years. Throughout follow up mortality during periods in which patients experienced angina was higher than in the symptom free periods. This long term follow up study of patients after a coronary event confirms that the presence or absence of angina may vary considerably over time in patients treated medically and that the presence of angina is associated with a poorer prognosis. These findings have important implications when assessing the effects of various treatment modalities on postcoronary angina, including coronary artery bypass surgery.     

Procaine (Novocain) Treatment of Patients with Senile and Arteriosclerotic Brain Disease

Of 32 patients (13 men and 19 women) with a mean age of 81.1 years committed to a mental hospital for senile or arteriosclerotic psychoses, 11 received 2% procaine hydrochloride according to Aslan''s method, for an average of 13 months, 11 for 6 months, and 10 normal saline. Of 20 patients, with a mean age of 72 years, who attended the geriatric psychiatric clinic of a general hospital, 10 were treated with procaine hydrochloride and 10 with normal saline for six months. Procaine hydrochloride applied for six or 12 months did not appreciably alter the symptomatology and course of senile and arteriosclerotic brain disease. It did not improve the senile amnestic syndrome or neurological symptomatology, when present. The general mood and level of activity improved temporarily. It was also temporarily helpful in alleviating depressive symptoms in patients suffering from arteriosclerotic brain disease.     

Hypercalcemia in infants presenting with apnea.

To our knowledge apnea in infants has not been associated with hypercalcemia. We describe seven hypercalcemic infants aged 2 days to 3 months who had presented with apnea; six of the seven were otherwise healthy. The apneic attacks were brief, and normal breathing was restored spontaneously or after tactile stimulation. The attacks stopped and the apnea monitoring was discontinued when the children were 1 month to 2 years of age. The only abnormal finding common to all of the patients was hypercalcemia. Idiopathic infantile hypercalcemia was diagnosed in six of the patients and familial benign hypercalcemia in one. Our findings suggest that determination of the plasma calcium level be included in the investigation of apnea in infancy.     

Does stopping smoking delay onset of angina after infarction?

This study was designed to determine the relation between stopping smoking and angina after infarction in survivors of an acute coronary attack. The study population comprised 408 men aged under 60 who survived a first attack of unstable angina or myocardial infarction by 28 days and were smoking cigarettes at the time of their attack. These patients were followed up for an average of nine years. Three hundred and eighty four were alive at the one year follow up examination, when the presence or absence of angina together with habits of smoking were recorded. The prevalence of angina at one year was 19.5% in the 241 who had stopped smoking cigarettes compared with 32.2% in those who had continued (p less than 0.01). Six years later, however, the prevalence of angina after infarction was the same in the two groups. It is concluded that the onset of angina after infarction can be delayed by stopping smoking cigarettes but that this effect is not maintained in the long term.     

Inoperable aortic stenosis in the elderly: benefit from percutaneous transluminal valvuloplasty.

Eight patients with severe symptomatic calcific aortic stenosis were considered to be unsuitable for valve replacement. Four were admitted with pulmonary oedema and three in cardiogenic shock and one had angina at rest. With the use of echocardiographic and radiographic guidance percutaneous transluminal aortic valvuloplasty was carried out. Aortic gradients were reduced by an average of 40%. All four patients who presented with cardiac failure improved immediately and remained well six months later. The patient with angina was symptom free at nine months. Two of the three patients who presented in cardiogenic shock improved immediately and were well nine and three months later. The other patient died four hours after the procedure. Doppler echocardiographic studies showed a slight initial increase in aortic incompetence, but this did not worsen and valvar gradients remained improved three and six months later. Percutaneous valvuloplasty of the aortic valve is an effective therapeutic option in patients with severe calcific aortic stenosis who are unfit for surgery. Its role as an alternative to surgery has not been considered and should be investigated in a controlled clinical trial.     

Self testing for diabetes mellitus.

OBJECTIVE--To develop a simple, economically viable, and effective means of population screening for diabetes mellitus. DESIGN--A postal request system for self testing for glycosuria with foil wrapped dipsticks. Preprandial and postprandial tests were compared with a single postprandial test. The subjects were instructed how to test, and a result card was supplied on which to record and return the result. All those recording a positive test result and 50 people recording a negative result were invited for an oral glucose tolerance test. SETTING--General practice in east Suffolk, list size 11534. PATIENTS--All subjects aged 45-70 years registered with the practice were identified by Suffolk Family Health Services Authority (n = 3057). The 73 subjects known to have diabetes from the practice''s register were excluded, leaving 2984 subjects, 2363 (79.2%) of whom responded. 1167 subjects completed the single test and 1196 the two tests. MAIN OUTCOME MEASURES--Response rate and number of patients with glycosuria. Sensitivity, specificity, and positive predictive value of a single postprandial test and preprandial and postprandial tests. Number of new cases of diabetes identified and cost of screening. RESULTS--Of the patients completing the single postprandial test, 29 had a positive result, an oral glucose tolerance test showed that eight (28%) had diabetes, six (21%) impaired glucose tolerance, and 14 (48%) normal glucose tolerance. 44 of the group who tested before and after eating had a positive result; nine (20%) had diabetes, five (11%) impaired tolerance, and 26 (11%) normal tolerance. Screening cost 59p per subject and 81 pounds per case detected. Of the 17 people with previously undiagnosed diabetes, eight were asymptomatic and 11 had not visited their general practitioner in the past three months. CONCLUSIONS--A postal request system for self testing for postprandial glycosuria in people aged 45-70 is a simple and effective method of population screening for diabetes mellitus.     

中性粒细胞／淋巴细胞比值与药物支架内再狭窄关系

目的：探讨经皮冠状动脉支架植入术前中性粒细胞／淋巴细胞比值（Neutrophil-to-LymphocyteRatio,NLR）与患者药物支架（DrugElutingStent,DES）植入后发生支架内再狭窄（In—StentRestenosis,ISR）的关系。方法：回顾性分析2012年01月至2012年10月间有DES植入史并再次入院接受冠脉造影的92例患者（平均年龄65．22±9．73岁）的血液学检查、既往冠脉造影结果及再次冠脉造影结果。根据DES植入前的NLR的四分位点将所有入选患者分为3组：最低三分位组（n=31,0．91-1．83）,中间三分位（n=30,1．87—2．63）,最高三分位（n=31,2．66—4．67）,比较3组间ISR发生率有无差异。结果：再狭窄发生在最低NLR三分位的有3例（9．68％）,发生在中间NLR三分位组的有2例（6．67％）,而有4例（12．90％）发生在NLR最高三分位组（P=0．714）,3组之间的差异无统计学意义。结论：因稳定或不稳定型心绞痛而植入药物支架的患者,其术前NLR同支架术后ISR的发生无明显相关性。NLR不能作为DES植入后发生再狭窄的预测指标。     

Be your own coroner: an audit of 500 consecutive deaths in a general practice.

General practitioners'' medical records of a geographically defined population of about 1600-1800 have been retained since 1964. Details of care by general practitioners and hospital correspondence were available for 500 deaths (277 men, 223 women) from 1964 to 1985, including deaths at home, at work, in the street, in short term and long term institutional care, and within six months of release from institutional care. The periods 1964-73 and 1974-85 were compared. The proportion of men aged greater than or equal to 80 who died increased from 20 (14%) in 1964-73 to 22 (16%) in 1974-85, but the proportion of women aged greater than or equal to 80 who died increased from 21 (23%) to 50 (39%). Of all deaths, 223 (45%) were thought to have had avoidable causal factors, of which 132 (59%) were attributed to patients, 45 (20%) to the general practitioner, 9 (4%) to hospitals, and 37 (17%) to others. The number of deaths related to smoking decreased from 31 (43%) in men aged less than 70 to 19 (30%) but in women aged less than 70 increased from 4 (10%) to 11 (26%). The proportion of deaths in women who were already dependent six months before death increased from 55 (58%) to 81 (63%) but in men remained constant at 64 (46%) in the first period and 62 (46%) in the second. Nearly two thirds of all deaths occurred at home in both periods--about twice the proportion for England and Wales--but the proportion of men dying at home decreased from 87 (62%) to 76 (56%). A critical analysis of deaths in whole populations by primary care teams can identify changes that are needed both in the work and organisation of the team and in the behaviour of the population itself.     

Lipoprotein (a) and coronary heart disease: a prospective case-control study in a general population sample of middle aged men.

OBJECTIVE--To examine the association between the serum lipoprotein (a) concentration and subsequent coronary heart disease. DESIGN--Prospective case-control study based on a six year follow up of a general population sample of men aged 50 at baseline in 1983-4. Serum samples were frozen at the time of the baseline examination and kept at -70 degrees C for six years, after which the lipoprotein (a) concentrations in the samples were measured in cases and controls. SETTING--City of Gothenburg, Sweden. SUBJECTS--26 Men, from a general population sample of 776 men, who had sustained a myocardial infarction or died of coronary heart disease during the six years and 109 randomly selected controls from the same sample who had remained free of myocardial infarction. In neither cases nor controls was there a history of myocardial infarction at baseline. MAIN OUTCOME MEASURES--Proportion of myocardial infarction or deaths from coronary heart disease, or both, in relation to the serum lipoprotein (a) concentration. RESULTS--Men who suffered coronary heart disease had significantly higher serum lipoprotein (a) concentrations than controls (mean difference 105 mg/l; 95% confidence interval 18 to 192 mg/l). Men with the highest fifth of serum lipoprotein (a) concentrations (cut off point 365 mg/l) suffered a coronary heart disease rate which was more than twice that of men with the lowest four fifths of concentrations. Logistic regression analysis showed the serum lipoprotein (a) concentration to be significantly associated with coronary heart disease independently of other risk factors. CONCLUSION--The serum lipoprotein (a) concentration in middle aged men is an independent risk factor for subsequent myocardial infarction or death from coronary heart disease.     

Life expectancy in men who have never smoked and those who have smoked continuously: 15 year follow up of large cohort of middle aged British men.

OBJECTIVE: To estimate the life expectancy in a representative sample of men who have never smoked and of those who have smoked all their adult lives. DESIGN: 15 year follow up of a large representative cohort of British men in the British regional heart study and use of national mortality statistics for 1992. SUBJECTS: 7735 middle aged British men aged 40-59 at the time of screening (between 1978 and 1980). MAIN OUTCOME MEASURES: Mortality from all causes and from smoking related causes. RESULTS: 1624 men had never smoked at the time of screening and did not take up smoking during the study. 127 of them died during follow up. 3151 men began smoking before they were 30 and were still smoking at the time of screening. Of these, 751 had stopped smoking five years after screening; they were excluded from the analysis five years after the date they had stopped. 560 of the lifelong smokers died during follow up. When study estimates were combined with those from national mortality statistics for men aged 20-40, only an estimated 42% (95% confidence interval 36% to 50%) of lifelong smokers alive at the age of 20 would be alive at 73, compared with 78% (74% to 82%) of lifelong non-smokers. CONCLUSION: These estimates present the effects of smoking on mortality in a way that is easily communicated to patients and the general public in health promotion initiatives.     

Return to work after coronary artery surgery for angina.

The working habits of 115 consecutive patients who underwent coronary artery vein bypass grafting for angina were assessed. Only 25 patients worked up to the operation. Seven patients were housewives and seven retired. Sixty-eight patients had had to give up work because of their angina pectoris, and most of these had been off work for between six months and two years. After the operation 75 patients returned to full-time work, 59 within two to six months. These 75 patients included 23 of the 25 at work preoperatively and 47 of the 68 unable to work preoperatively. Most patients returned to their original occupation. We conclude that coronary artery surgery, as well as bringing symptomatic relief, increases the patient''s ability to return to and maintain gainful employment.     

National asthma attack audit 1991-2. General Practitioners in Asthma Group.

OBJECTIVE--To describe the frequency and characteristics of asthma attacks in the United Kingdom and to compare actual management with recommended guidelines for the management of attacks. DESIGN--Correspondence survey. SETTING--218 general practices in the United Kingdom. SUBJECTS--1775 patients of all ages who had a total of 1805 asthma attacks over three months. MAIN OUTCOME MEASURES--Patient characteristics, place of management of attacks, comparison of actual management with recommended guidelines. RESULTS--Of the 1805 attacks, 300 occurred in boys aged 0-9, 144 in girls aged 0-9, and 118 in women aged 20-29. The estimated frequency of attacks in the community was 14.3 per 1000 patients per year. 1546 (86%) patients with attacks were managed within general practice, 225 (12%) were admitted to hospital, and 34 (2%) were discharged from an accident and emergency department. Two patients died. On initial presentation, 248 (14%) patients were "not breathless," 900 (50%) were "moderately breathless," 535 (30%) were "breathless and distressed," 68 (4%) were "too breathless to talk," and 2 were "moribund." Recording of clinical data was variable. Underuse of nebulised bronchodilators and systemic steroid was apparent in all grades of clinical severity. Contrary to current guidelines for asthma management, "step up" in maintenance therapy after an attack was often not practised. CONCLUSION--Reported management was at variance with recommended guidelines. This has major implications for the design and distribution of future guidelines.     

Sexual activity after myocardial infarction.

Questionnaires on sexual activity were completed by 161 patients attending an exercise-centred rehabilitation program an average of some 3 years after a myocardial infarction. In almost half the group, sexual activity was unchanged or increased compared with the period before the infarction. In the remainder it was reduced; this group included 29 men who had adopted a more passive sexual role and 26 who were now having angina or ventricular premature beats during intercourse. Although the patients with diminished activity could not be distinguished by means of formal personality test, questionnaires completed by their wives suggested that they were less willing to assume responsibility, had increased difficulty in adjusting to life at home and at work and were more neurotic and depressed than those with normal or increased activity. Furthermore, those with decreased sexual activity had a poorer response to training in terms of attendance, final average jogging distance and gains in physiologic status. Since the frequency of angina and ventricular premature beats was less during intercourse than during standard laboratory exercise, it was concluded that normal sexual relations carry no special risk for the average postcoronary patient; indeed, by enhancing self-esteem and encouraging effective participation in an exercise programm, acceptance of normal sexual activity may improve the prognosis.     

Colchicine Use for Familial Mediterranean Fever—Observations Associated With Long-term Treatment

Of 85 patients with familial Mediterranean fever receiving continuous prophylactic colchicine therapy, 62 (73 percent) have had a significant reduction in the severity and frequency of their attacks. All 62 have been observed for three years or more, for a total of 4,680 patient-months and a mean duration of 75.5 months. Of the 85 patients, 23 (27 percent) did not complete three years of treatment for a variety of reasons. Diarrhea was the most common side effect, necessitating reduction of colchicine dosage in 12 patients, but discontinuation of treatment in only one. No other significant side effects were observed. Continuous, prophylactic colchicine therapy is effective in preventing the recurrent febrile paroxysms of familial Mediterranean fever and is indicated in those patients who are incapacitated by frequent attacks or who are at risk for amyloidosis developing.     

Nd-YAG Laser in Lung Cancer

We administered 45 Nd-YAG laser treatments in 29 patients (18 men) aged 39 to 82 years who had lung malignancy; 26 patients had primary non-oat cell lung cancer and three had metastatic airway malignancy. In all, 25 of the patients had been previously treated with combination(s) of surgical procedure, radiation therapy and chemotherapy. Indications for laser treatment included endobronchial airway obstruction with uncontrolled cough, hemoptysis, dyspnea or unresolved atelectasis-pneumonia. Of 15 patients with partially occluded tracheobronchial airway tumors, immediate palliative relief was achieved in 13 patients and lasted one to six months after a single treatment. In this group there was one postoperative death related to respiratory failure and two patients subsequently died of massive pulmonary hemorrhage. However, of 14 patients with totally obstructed airways, immediate palliative relief was achieved in only five patients and this lasted three weeks to three months after a single treatment. In this group there were two postoperative deaths related to progressive respiratory failure; in one case it was associated with endobronchial combustion of the fiberoptic bronchoscope. All three patients in both groups who died of respiratory failure were in acute respiratory distress and terminally ill before the procedure. These findings suggest that Nd-YAG laser therapy may be most beneficial in patients with partially rather than totally occluded airways due to lung malignancy.     

Population based study of fatigue and psychological distress.

OBJECTIVES--To determine the prevalence of fatigue in the general population and the factors associated with fatigue. DESIGN--Postal survey. SETTING--Six general practices in southern England. SUBJECTS--31,651 men and women aged 18-45 years registered with the practices. MAIN OUTCOME MEASURES--Responses to the 12 item general health questionnaire and a fatigue questionnaire which included self reported measures of duration, severity, and causes of fatigue. RESULTS--15,283 valid questionnaires were returned, giving a response rate of 48.3%, (64% after adjustment for inaccuracies in the practice registers). 2798 (18.3%) of respondents reported substantial fatigue lasting six months or longer. Fatigue and psychological morbidity were moderately correlated (r = 0.62). Women were more likely to complain of fatigue than men, even after adjustment for psychological distress. The commonest cited reasons for fatigue were psychosocial (40% of patients). Of 2798 patients with excessive tiredness, only 38 (1.4%) attributed this to the chronic fatigue syndrome. CONCLUSION--Fatigue is distributed as a continuous variable in the community and is closely associated with psychological morbidity.     

Assessment of cardiac risk 10 days after uncomplicated myocardial infarction.

A total of 188 patients with uncomplicated acute myocardial infarction (long-term Norris prognostic index 3.2) were rapidly mobilised, underwent a symptom-limited exercise test around the day of discharge from hospital (day 10), and returned to work at a median of six weeks after the acute event. The incidence of cardiac death six months, one year, and three years after infarction was 2.7%, 4.5%, and 7.3% respectively, and the corresponding figures for recurrent heart attacks were 3.4%, 8.2%, and 18.5% respectively. The risk of recurrence of heart attack was predicted by three variables assessed at discharge--namely, a history of classical effort angina (p less than 0.01), radiological heart failure (p less than 0.05), and angina induced by the exercise test (p less than 0.05). The presence of any of these risk factors defined a group of patients with a sevenfold risk of recurrent heart attacks within six months of the initial acute infarct. It is concluded that these risk factors identify a group of patients with a high risk of recurrence early after infarction, in whom vigorous secondary prophylaxis is desirable.     

Predictive value of rectal bleeding in screening for rectal and sigmoid polyps.

Overt rectal bleeding is a common symptom of colorectal cancer and polyps but also occurs in apparently healthy people. It is not known how often this represents bleeding from an undiagnosed rectal or sigmoid polyp or cancer. Three hundred and nineteen apparently healthy men aged over 50, selected by random sampling, were interviewed and underwent flexible sigmoidoscopy to at least 30 cm. Polyps of 10 mm or more in diameter were diagnosed in 12, one of whom also had an adenocarcinoma. Rectal bleeding during the previous six months was reported by 48, four of whom were found to have polyps; seven polyps and one cancer were diagnosed among the 271 who reported no rectal bleeding. Rectal bleeding had a specificity of 86%, a sensitivity of 33%, and a positive predictive value of 8% for rectal or sigmoid polyps or cancer. Restricting the analysis to those subjects who regularly inspected their stools did not improve the predictive value. Sigmoidoscopy in apparently healthy subjects with rectal bleeding will not result in the diagnosis of appreciable numbers of rectal and sigmoid polyps or cancers.